/ 9 June 2013

Deadly initiation: Govt lacks numbers on circumcision deaths

In addition to being circumcised
In addition to being circumcised

The state has been unified in its calls for better monitoring and interventions to improve the outcomes of traditional circumcision. But how can the state intervene in a process on which it does not even have basic data? When the Mail & Guardian canvassed officials for information on the numbers of deaths and mutilations caused by botched circumcisions each year, reporters were sent from pillar to post in search of statistics.

There was national outrage in May when news emerged that 27 boys died during initiation in Mpumalanga province. President Jacob Zuma echoed the national outrage at the unnecessary loss of lives, saying: "It cannot be acceptable that every time young men reach this crucial time in their development, their lives are culled in the most painful of ways in the care of circumcision schools."

By the time a snap debate on the issue was called in Parliament, the death toll approached 40. MPs defended cultural practices, called for the arrest of those responsible for the deaths, a clampdown on fly-by-night initiation schools and "culturepreneurs", and demanded better monitoring of the initiation process to ensure safe health practices.

But with poor record keeping at the outset, it's unclear whether the state has any sort of plan to prevent the death and mutilation of the boys who would be men.

Reliable statistics
Initiation may be a highly valued cultural practice but there are no indications that government tracks the issue of deaths and mutilations caused during it. 

There do not appear to be any reliable national statistics on the number of boys who undergo initiation each year, nor the number who die or are mutilated as a result of traditional circumcision.

According to Health Minister Aaron Motsoaledi, the main medical issues that can cause death in initiates are massive bleeding leading to hypovolemic shock, infection, septicaemic shock, dehydration from being denied drinking water, hypothermia from exposure to extreme weather, and low blood sugar from extreme food restriction. Poor circumcision technique can lead to genital amputation. In some cases, the cause of death is assault.

Of the three provinces in which initiation is most commonly practiced, the M&G was only able to get statistics from one, the Eastern Cape.

In that province, the death toll for the five years from 2008 to 2012 was 323. During that time, a further 126 boys suffered genital amputations.

An effective intervention strategy cannot be put into place unless government has an indication of the state of play in each province where initiation is practiced.

Referred questions
Initiation is most commonly practiced in the Eastern Cape, Limpopo and Mpumalanga.

The Limpopo and Mpumalanga health departments could not provide numbers and referred further questions to traditional leaders and the department of traditional affairs.

Sizwe Kupelo, a spokesperson for the Eastern Cape health department, said that keeping these statistics was possible because the department works together with Eastern Cape House of Traditional leaders, local government and various community structures.

The Eastern Cape has a head start on other provinces – in 2001 it became the first province to introduce legislation regulating traditional circumcision in an attempt to curb deaths and genital mutilation taking place in the bush. 

In contrast, Mpumalanga has yet to finalise its initiation Bill.

Why statistics are important
Having statistics on this issue is a key part of improving the health outcomes of traditional circumcision.

"It helps a lot because it gives us indications of where intervention and more resources are needed the most per season," said Kupelo.

But even if provincial health departments tracked this issue, it's unclear whether there would be sufficient data to get a clear picture of the toll that botched circumcisions have in South Africa. 

Although it seems to be the exception, there have been cases involving bogus initiation schools in which children are routinely beaten and assaulted, some to the extent that they died. Some reported being denied food and water

The South African Human Rights Commission said in February it would investigate a case in the Northern Cape in which one person died at an illegal initiation school.

Official records cannot shed light on the deaths that occur at illegal initiation schools or at those where the tradition is to manage complications and deaths "in the bush".

Democratic Alliance spokesperson on traditional affairs George Boinamo pointed out that not all boys who are injured report to hospitals for treatment and that not all boys who die following traditional circumcision find their way to mortuaries.

"If an initiate dies at initiation schools, the culture is you don't bring the body home. The body is buried at the initiation school, in the bush wherever they are in the mountain. The death is not reported before the burial," he said.

The tradition of burials
Last week Boinamo visited Zelisha Moremi, whose son Tshepo died at an initiation school. Moremi told Boinamo that after her son was taken to a mortuary, a group of men came from the initiation school and demanded that his body be returned.

"They said they have to bury him, and not the family. It's the tradition, according to [them]," said Boinamo.

Boinamo said he was not aware of any laws compelling traditional leaders to report these numbers to the state.

The Congress of Traditional Leaders of South Africa referred questions on the number of boys who undergo initiation nationally and those injured in the process to the co-operative governance and traditional affairs department.

The department's Charles Nwaila said that there was no compiled database of the number of boys who undergo initiation each year or of those who are injured or die each year. This information had to be sought from the provincial departments. 

While Nwaila received such figures from the Eastern Cape and Limpopo, he had not from Mpumalanga.

"They keep it as a secret," he said.

A serious matter
If government is to take this matter seriously, a first step should be to compel provinces to share their information with national government. 

Problems with data collection are also evident when it comes to law enforcement.

Despite calls for the law to take its course, it's unclear whether there are any legal repercussions when it comes to the malpractice and negligence that leads to the death and mutilation of an unknown number of boys each year.

The nature of data collection at both the National Prosecuting Authority and the South African Police Service means that there is no way to tell whether any of the cases prosecuted – be they for murder, assault or negligence – were related to botched circumcisions.

Without these statistics there can be no way to tell whether anyone has ever been brought to account for these deaths or whether they have been allowed to continue with unsafe circumcision practices away from prying eyes.

Last month, the Public Service Accountability Monitor slammed government and traditional leaders for failing to protect initiates.

No prosecutions
Jay Cruus, director of the organisation, said he was unaware of any cases in which those responsible for the deaths or mutilations of initiations had been prosecuted under the law. 

"I've never heard of one [case], despite the high death rates and the mutilations. I haven't encountered a case where the police have taken that course of action. I haven't even heard of a medical negligence suit against these initiation schools, be they authorised or rogue," he said.

Cruus said that the starting point for accountability should be legislation.

"It needs to be law that these kinds of figures need to be submitted – the number of people who've gone through the process, the number of people who had complaints, and so forth," he said.

Dr Dan Ncayiyana, editor emeritus of the South African Medical Journal, also blamed a lack of accountability for the continuing deaths and mutilations.

"At the core of this matter is the lack of accountability. It just seems no one is accountable. It seems everyone is passing the buck. National government says provincial government must deal with it, provincial government says traditional leaders must deal with it, and so forth," he explained.

Ncayiyana said he asked an MP to ask a question in Parliament on the number of people apprehended, prosecuted and convicted for their involvement in these kinds of deaths. 

"She did put the question [to the minister] but to my knowledge it was never answered," said Ncayiyana.

"Nobody is being held to account, and that's the problem."